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Abstract Background The six core competencies of ACGME - patient care (PC), medical knowledge (MK), systems-based practice (SBP), practice-based learning and improvement (PBLI), professionalism (PROF), and interpersonal and communication skills (ICS) - represent domains in which physicians must ultimately demonstrate competence. Although the ACGME’s six core competencies have been applied in Taiwan with the milestone project, the application of the six core competences in the Family Medicine milestones for residency training have not yet been established. Methods We recruited 61 family medicine physicians from 25 hospitals from four major geographic areas for a Delphi round one survey and 72 physicians from 27 hospitals for a Delphi round two survey. With 5-point scales, the Cronbach’s alphas for both importance and fitness were 0.98 in round one. In round two, the Cronbach’s alphas were 0.86 and 0.83 for importance and fitness. The mode and quartile deviation in Delphi method, importance-performance analysis (IPA), and importance-performance matrix analysis (IPMA) were used for three stages IPA process. Results In IPA, a total of 72.7% (16/22) of the sub-competencies exhibited high importance and fitness, with a mean score ≥ 4.7; the exceptions were PC-1 (cares for acutely ill or injured patients), MK-2 (critical thinking skills in patient care), SBP-1 (cost-conscious medical care), PBLI-3 (improves systems), PROF-3 (humanism/cultural proficiency), and ICS-4 (utilizes technology). In IPMA, the performance value of six core competencies for FMM-Taiwan was 92.6 when considering the importance and fitness indices of the 22 sub-competencies. Conclusions The accordance of the ACGME’s milestones to Taiwan was acceptable to good and related milestones could been developed for residency training.

ChatGPT, a large language model, has gained significance in medical writing, particularly in case reports that document the course of an illness. This article explores the integration of ChatGPT and how ChatGPT shapes the process, product, and politics of medical writing in the real world. We conducted a bibliometric analysis on case reports utilizing ChatGPT and indexed in PubMed, encompassing publication information. Furthermore, an in-depth analysis was conducted to categorize the applications and limitations of ChatGPT and the publication trend of application categories. A total of 66 case reports utilizing ChatGPT were identified, with a predominant preference for the online version and English input by the authors. The prevalent application categories were information retrieval and content generation. Notably, this trend remained consistent across different months. Within the subset of 32 articles addressing ChatGPT limitations in case report writing, concerns related to inaccuracies and a lack of clinical context were prominently emphasized. This pointed out the important role of clinical thinking and professional expertise, representing the foundational tenets of medical education, while also accentuating the distinction between physicians and generative artificial intelligence.

Abstract Background Terminally ill patients often experience exacerbations of diseases that render mainstream medicine ineffective in relieving symptoms, prompting attempts at complementary and alternative medicine (CAM). This study collected data from terminally ill patients and their relatives to determine differences between CAM use, behavioral patterns, and perceptions of health information about CAM. Methods A cross-sectional design using a self-administered questionnaire was adopted. Eight medical institutions in Taiwan with inpatient hospice palliative care units were chosen. Ninety-two terminally ill patients and 267 relatives met the inclusion criteria. The questions concerned the experience of CAM use, the kinds of products/services CAM provided, the purpose of CAM use, the source of CAM information, and the perceptions and attitudes toward CAM. Results Both terminally ill patients and their relatives have a high proportion of lifetime and one-year prevalence of CAM use (88.0% vs. 88.4%; p = 0.929). CAM use for musculoskeletal and neurological discomfort is higher among terminally ill patients than among their relatives. Relatives/friends are the most frequent sources of information on CAM (53.3% vs. 62.2%; p = 0.133). The percentage of terminally ill patients who discontinued mainstream medical treatment because of CAM use was higher than that of their relatives (18.5% vs. 9.3%; p = 0.026). More than half the terminally ill patients and their relatives had never been asked about CAM by medical staff (64.1% vs. 66.7%), nor had they informed medical professionals about the use of CAM products and services (63% vs. 66.9%). Random inquiries by medical professionals may be associated with increased disclosure of CAM use (terminally ill patients: odds ratio, 9.75; 95% confidence interval, 1.97–48.35 vs. relatives: odds ratio, 5.61; 95% confidence interval, 2.66–11.83). Conclusions The high prevalence and concealment of CAM use in terminally ill patients should be considered. Medical professionals should establish a friendly and barrier-free communication model, encourage patients to share CAM experiences, and provide evidence-based information on the use of CAM products and services, to reduce the potential damage caused by harmful use.

Background: The time from submission to publication can significantly impact the speed of knowledge dissemination and is influenced by multiple factors. This research aims to investigate the time from submission to publication of journals of primary health care and to explore the factors that influence this duration. Methods: We selected journals of primary health care and extracted their impact factors, annual publication frequencies, and open access status. The time from submission to acceptance (SA lag), acceptance to publication (AP lag), and submission to publication (SP lag) were calculated. Additionally, we conducted statistical analyses to determine whether impact factors, annual publication frequencies, and journal open access status had an influence on publication time. Results: This study revealed the average SP lag was 243.4 days (interquartile range, IQR 159–306), the average SA lag was 177.8 days (IQR 99–229.3), and the average AP lag was 65.6 days (IQR 14–101). Variations were observed in SP lag, SA lag, and AP lag among different journals. SP lag generally decreased with higher impact factors. Journals with open access had longer SA lag but shorter AP lag. There was a general trend of decreasing SP lag and SA lag with an increasing number of annual publications, but no clear trend was observed for AP lag. Conclusions: Improvements are needed in reducing the duration from submission to publication for primary health care journals. Significant variation exists among journals. Additionally, factors such as the impact factor, open access status, and the number of annual publications may influence publication speed.

This study evaluates the incidence and characteristics of adverse events (AEs) following the second COVID-19 booster dose, leveraging Taiwan’s distinctive approach of extending booster vaccinations to all citizens, unlike the targeted high-risk group strategies in other countries. Utilizing data from Taipei Veterans General Hospital’s Vaccine Adverse Event Reporting System (VAERS) from 27 October 2022 to 19 January 2023, this research examines AEs in 441 out of 1711 booster recipients, considering factors like age, vaccine brands, and booster combinations. The findings revealed incidence rates (IRs) of 25.6% (95% CI: 21.1–30.8) after the first booster and 24.9% (95% CI: 20.5–30.0) after the second, mostly non-serious, with those having AEs post-first booster being five times more likely to report them again (incidence rate ratio, 5.02, p < 0.001). Significantly, switching from the mRNA1273 vaccine to another brand reduced AE risk by 18%. This study underscores that AEs are more repetitive than cumulative with additional booster doses, advocating for personalized vaccination strategies based on individual medical histories and previous vaccine reactions. These insights are valuable for healthcare providers in discussing potential AEs with patients, thereby improving vaccine compliance and public trust, and for policymakers in planning future booster vaccination strategies.

Objectives Compassionate community models, successfully applied in several Western countries, have not been extensively promoted in Asian countries. This study explored primary care staff’s willingness to participate and factors associated with their participations in compassionate community education and network, palliative care education, providing palliative care and the barriers they faced.Methods Adopting a mixed quantitative–qualitative design, primary care staffs in Beitou and Shilin districts in Taiwan, including physicians, nurses, pharmacists and administrative staff aged ≥20 years who had worked in a clinic for more than 2 months, were recruited. A questionnaire survey was conducted to explore their willingness to participate in compassionate community education and networks and palliative care education and care provision. Logistic regression was used to evaluate factors associated with their willingness, and qualitative perceptions were evaluated by open questions.Results About half of the respondents were willing to participate in compassionate community education and network and palliative care education, but only 19.5% were willing to provide palliative care. Compared with other staff, primary care nurses showed significantly more willingness to participate in compassionate community education and network and palliative care education and to provide palliative care. However, physicians were significantly not willing to participate in any of the three services apart from providing care. Capability, administrative and manpower concerns, time, age and motivation were the main barriers.Conclusions To encourage primary care staff to participate more in compassionate community education and network and palliative care education and to provide palliative care, policymakers should pay more attention towards removing the barriers to their engagement.

Background: Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care. Methods: This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson’s Chi-square test and Fisher’s exact test. Results: A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care. Conclusions: Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

Introduction In contrast to other countries, Taiwan’s National Health Insurance (NHI) program allows patients to freely select the specialists and tiers of medical care facility without a referral. Some medical centers in Taiwan receive over 10,000 outpatients per day. In the NHI program, the co-payment was increased for high-tier facilities for outpatient visits in 2002, 2005, and 2017. However, the policies only mildly reduced the use of high-tier medical care facilities. The main purpose of this study was to evaluate the factors contributing to the patients’ selection of the outpatient clinic of medical centers without a referral. Methods An online anonymous survey was conducted by using the Google Forms platform utilizing a self-constructed questionnaire from September to October 2018. A nationwide sample in Taiwan was recruited using convenience sampling through social media. Based on a literature review and a focus group, 20 factors that may affect the choice of the outpatient institution were constructed. The associations between items that affect the patients selection of outpatient clinics were assessed using exploratory factor analysis. Principal axis factoring was performed to identify the major factors affecting the decision. Multiple logistic regression was performed to determine which factors satisfactorily explained “visiting the outpatient clinic of the medical center for an illness without a referral.” Results During the survey period, 5,060 people browsed the online survey, and 1,003 responded and completed the online questionnaire. Therefore, the response rate was 19.8%. A total of 987 valid responses was collected. Exploratory factor analysis revealed that three main factors, namely the “physician factor”, “image and reputation factor”, and “facility and medication factor”, affected the selection of outpatient clinics. A series of logistic regressions indicated that patients who reported that hospital facilities, high-quality drugs, and diverse specialties were very important were more likely to select the outpatient clinic of a medical center (OR = 2.218, 95% CI [1.514–3.249]). Patients who reported that physician factors were very important were less likely to select a medical center (OR = 0.717, 95% CI [0.523–0.984]). Patients who were previously satisfied with their experience of the primary clinics or had a regular family doctor were less likely to choose a medical center (OR = 0.509, 95% CI -0.435–0.595] and OR = 0.676, 95% CI [0.471–0.969]). Conclusion In Taiwan, patients with good primary medical experience and regular family physicians had significantly lower rates by selecting the outpatient clinic of a medical center. The results of this study support that the key to establishing graded medical care is to prioritize the strengthening of the primary medical system.

Abstract Background Metabolic syndrome (MetS) is a widespread condition with important effects on public health, in general. There is a lack of relevant research on possible sex differences in the relationship between MetS and health-related quality of life (HRQoL) and also the sex differences in factors associated with HRQoL. The aims of this study were to identify: 1) whether women exhibit greater negative impacts on physical domain HRQoL from MetS compared with men; 2) whether women exhibit greater mental domain impacts compared with men; and 3) whether factors associated with HRQoL scores are different for men and women. Methods This cross-sectional study was conducted in Taipei, Taiwan. Using random sampling, a total of 906 participants aged 35–55 years were recruited. MetS was defined according to the MetS criteria for the Taiwanese population, and HRQoL were assessed using physical component summary (PCS) and mental component summary (MCS) scores of the Short Form Health Survey (SF-36), Taiwan version. Demographics, physical activity, medical history, and blood tests as covariates were recorded and checked. The associations were assessed by multiple linear regression. Results After adjusting for covariates, women but not men with more components of MetS had significantly lower PCS scores (β = − 0.542, p = 0.036). The number of components of MetS was not a significant factor in MCS score differences between the sexes. Furthermore, there were sex differences regarding age, education level, physical activity, and smoking status in association with PCS scores. For MCS scores, sex differences were found in education level, marital status, and habits of smoking and alcohol consumption. Conclusions There were sex differences in the relationships between metabolic syndrome components and factors associated with HRQoL among middle-aged adults living in the community in Taiwan. Further research should be conducted to investigate mechanisms of these sex differences.

Abstract Background In 2009, the Taiwanese national health insurance system substantially expanded hospice coverage for terminal cancer patients to include patients with end-stage brain, dementia, heart, lung, liver, and kidney diseases. This study aimed to evaluate differences in do-not-resuscitate (DNR) status and hospice care utilization between terminal cancer patients and advanced non-cancer patients after the policy change. Methods Data were obtained from the Death and Hospice Palliative Care Database of Taipei Veterans General Hospital in Taiwan. The differences between cancer and non-cancer patients who died in this hospital between 2010 and 2015 were analyzed in terms of patient characteristics, rates of DNR orders, hospice care utilization, number of living days after DNR order, duration of survival (DOS) after hospice care enrollment, and the rate of late referral to hospice care. Results Data for 8459 patients who died of cancer and major non-cancer terminal diseases were included. DNR order rate, hospice care utilization rate, and DOS were significantly higher for cancer patients than for non-cancer patients (p

Objective: Obstetrician–gynecologists are the main providers of women's healthcare. However, workforce shortages and excessive workloads among these providers have been encountered in many countries. While most past studies on this subject have investigated the spatial distribution of obstetrics–gynecology clinics, few have focused on their temporal availability, especially on the national level. Materials and methods: The weekly opening time schedules (divided into morning, afternoon, and evening sessions) of all obstetrics–gynecology clinics in Taiwan were extracted from the web site of Taiwan's National Health Insurance Administration in July 2015. The numbers of open sessions were then analyzed and stratified by urbanization level and practice type. Results: Among 742 obstetrics–gynecology clinics in Taiwan, 521 were located in urban areas, 194 in suburban areas, and 27 in rural areas. The numbers of open sessions per week in suburban areas were higher than those in urban and rural areas (16.7 ± 2.6 vs. 15.9 ± 3.1 and 15.9 ± 2.7). Group practices had more open sessions per week than solo practices (16.8 ± 2.8 vs. 15.8 ± 3.0). With respect to after-hours services in rural areas, only two rural obstetrics–gynecology clinics remained open on Sunday mornings, while none remained open on Sunday afternoons and evenings. Conclusion: Obstetrics–gynecology clinics in Taiwan offered great temporal availability. In addition to the remarkable urban–rural disparity in the distribution of obstetrics–gynecology clinics, the availability of services on Sundays in rural areas demands special attention.

The shortage and maldistribution of pediatricians affected after-hours pediatric services, especially in rural areas. Our study aimed to examine the urban-rural disparity in geographical and temporal availability of the pediatrician workforce in Taiwan by analyzing opening time schedules of all pediatric clinics throughout the country. Methods: The opening time schedules of nonhospital pediatric clinics were downloaded from the website of the National Health Insurance Administration in Taiwan for analysis. The geographical and temporal availability of pediatric clinics was calculated and stratified by urbanization level and opening time, which was divided into daytime and evening sessions over 1 week. Each of 368 towns in Taiwan was also regarded as a unit of measurement to estimate the local availability of at least one pediatric clinic open in after-hours sessions. Results: Among 1483 nonhospital pediatric clinics in Taiwan, the overwhelming majority were situated in urban (65.8%) and suburban (30.6%) areas. On average, a pediatric clinic provided 16.3 (standard deviation = 3.04) sessions of services per week. One-third (34.7%, n = 50) of 144 suburban towns and over three-fourths (77.4%, n = 120) of 155 rural towns had no pediatric clinic. Most pediatric clinics remained open on weekday evenings (91.1%) and during Saturday daytime (91.8%). The percentage of open clinics gradually decreased over the weekend: Saturday evening (58.1%), Sunday daytime (33.4%), and Sunday evening (19.4%). Rural pediatric clinics remained closed mostly on weekends. On Sunday evenings, pediatric clinics were open only in 5.2% of rural towns, with a decline of 77.1%, whereas they were open in 78.3% of urban towns, with a decline of 18.2%. Conclusion: Pediatric clinics in Taiwan were unevenly distributed between urban and rural areas. The disparity of pediatric services became more obvious at weekends. The consequences of undersupplied rural pediatric care deserve further investigation.

Objective Volunteering, an important aspect of society, is a multidisciplinary issue. However, there few are extensive surveys examining the trend and scope of research on volunteering in biomedical areas. Methods Publications indexed with the Medical Subject Headings “volunteers” or “hospital volunteers” were downloaded from MEDLINE. We excluded publications indexed with “healthy volunteers” from the analysis. Results A total 3555 research articles on volunteering were found in 1283 journals, through the end of 2016. The number of publications increased gradually from 1 article in 1953 to 254 articles in 2016. Only 51 journals had published 10 or more articles on this topic. Research articles on volunteering were published in journals with 110 specialties and were most often in journals related to public health, nursing, and health services. The largest proportion of articles was related to psychology. Although 10,853 authors were identified in 3555 articles, only eight authors have published more than 10 research articles on volunteering. Conclusion Research interest in volunteering in biomedical areas has been growing in recent decades, but the total number of publications on volunteering remains relatively small.

Family physicians serve as personal doctors for individuals and their families and also act as gatekeepers of the health care system. If no special status is accorded to family physicians, however, then the rates at which health care recipients utilize their service might be affected. In the present cross-sectional study, representative claims data sets for 2010 from Taiwan’s National Health Insurance program, a health care system in which beneficiaries are not required to register with a family physician, were used to investigate the provision of health care to the population by family physicians. Among 919 206 beneficiaries with a total of 13 713 199 ambulatory visits, 49.1% had visited family physicians, 34.1% had visited internists, 24.3% had visited pediatricians, and 38.9% had visited otolaryngologists. Women (χ 2 (1) = 538, P < .001) and patients aged 65 and above (χ 2 (1) = 16 000, P < .001) had a higher proportion of visiting family physicians rather than visiting other specialties. The onion-shaped population pyramid with family medicine visits was compatible with the general population, and the proportion of visiting family physicians increased with increasing age. Among 112 289 patients with essential hypertension, 63 379 patients with diabetes mellitus, and 80 090 patients with hyperlipidemia, only 35.3%, 32.0%, and 31.1%, respectively, had visited family physicians. The age and sex distributions of these patients were illustrated with population pyramids for data visualization and direct comparisons. Taken together, the results of this study indicate that the utilization of family physicians in Taiwan and the effectiveness of their associated role in chronic disease management still have room for improvement.

Background: Metabolic syndrome (MetS), associated with the risk of cardiovascular disease and stroke, resulted in subsequent functional decline among aging population. It would be of interest to investigate the characteristics and related health behaviors of MetS among community-dwelling elderly. Methods: During 2007–2010, we selected the elderly who underwent the annual health checkup and screen in Taipei Veterans General Hospital and did not have MetS in their first year of participation as the study population. After a mean of 2.8 years' follow-up, the elderly were categorized into new-developed MetS patients and non-MetS patients according to Adult Treatment Panel III diagnostic criteria of MetS. Health behaviors were collected using a questionnaire and the laboratory data were analyzed. Results: A total of 888 community-dwelling elderly were enrolled. Of those participants, 206 (23.2%) developed MetS (new-developed MetS group) and 682 (76.8%) did not develop MetS (non-MetS group). Presence of higher initial MetS score, hyperuricemia, and proteinuria, and lack of exercise were associated with new-developed MetS in the elderly. Proteinuria and initial MetS score of two patients were significantly related to the development of MetS in the Cox regression analysis (hazard ratio 2.530 and 4.728, respectively). Other health behaviors such as smoking, alcohol drinking, teeth brushing, vegetable intake, and milk intake were not correlated significantly with the development of MetS. Conclusion: For the community-dwelling elderly, proteinuria and initial MetS score of two participants were correlated to the occurrence of MetS. A stricter control of risk factors of MetS in these elderly is necessary.

The term “palliative care” has a negative connotation and may act as a barrier to early patient referrals. Rebranding has thus been proposed as a strategy to reduce the negative perceptions associated with palliative care. For example, using the term “supportive care” instead of “palliative care” in naming palliative care units has been proposed in several studies. In Taiwan, terms other than “palliative” and “hospice” are already widely used in the names of palliative care units. With this in mind, this study investigated the characteristics of palliative care unit names in order to better understand the role of naming in palliative care. Relevant data were collected from the Taiwan Academy of Hospice Palliative Medicine, the National Health Insurance Administration of the Ministry of Health and Welfare, and the open database maintained by the government of Taiwan. We found a clear phenomenon of avoiding use of the terms “palliative” and “hospice” in the naming of palliative care units, a phenomenon that reflects the stigma attached to the terms “palliative” and “hospice” in Taiwan. At the time of the study (September, 2016), there were 55 palliative care units in Taiwan. Only 20.0% (n = 11) of the palliative care unit names included the term “palliative,” while 25.2% (n = 14) included the term “hospice.” Religiously affiliated hospitals were less likely to use the terms “palliative” and “hospice” (χ 2 = 11.461, P = .001). There was also a lower prevalence of use of the terms “palliative” and “hospice” for naming palliative care units in private hospitals than in public hospitals (χ 2 = 4.61, P = .032). This finding highlights the strong stigma attached to the terms “palliative” and “hospice” in Taiwan. It is hypothesized that sociocultural and religious factors may partially account for this phenomenon.

The family medicine researches flourished worldwide in the past decade. However, the collaborative patterns of family medicine publications had not been reported. Our study analyzed the collaborative activity of family medicine researchers in Taiwan. We focused on the types of collaboration among disciplines, institutions and countries. We searched “family medicine” AND “Taiwan” in address field from Web of Science and documented the disciplines, institutions and countries of all authors. We analyzed the collaborative patterns of family medicine researchers in Taiwan from 2010 to 2014. The journal’s impact factor of each article in the same publication year was also retrieved. Among 1,217 articles from 2010 to 2014, interdisciplinary collaboration existed in 1,185 (97.3%) articles, interinstitutional in 1,012 (83.2%) and international in 142 (11.7%). Public health was the most common collaborative discipline. All international researches were also interdisciplinary and interinstitutional. The United States (75 articles), the United Kingdom (21) and the People’s Republic of China (20) were the top three countries with which family medicine researchers in Taiwan had collaborated. We found a high degree of interdisciplinary and interinstitutional collaboration of family medicine researches in Taiwan. However, the collaboration of family medicine researchers in Taiwan with family medicine colleagues of other domestic or foreign institutions was insufficient. The future direction of family medicine studies could focus on the promotion of communication among family medicine researchers.

Although family medicine (FM) is the most commonly practiced specialty among all the medical specialties, its practice patterns have seldom been analyzed. Looking at data from Taiwan’s National Health Insurance Research Database, the current study analyzed ambulatory visits to FM specialists nationwide. From a sample dataset that randomly sampled one out of every 500 cases among a total of 309,880,000 visits in 2012, it was found that 18.8% (n = 116, 551) of the 619,760 visits in the dataset were made to FM specialists. Most of the FM services were performed by male FM physicians. Elderly patients above 80 years of age accounted for only 7.1% of FM visits. The most frequent diagnoses (22.8%) were associated acute upper respiratory infections (including ICD 460, 465 and 466). Anti-histamine agents were prescribed in 25.6% of FM visits. Hypertension, diabetes and dyslipidemia were the causes of 20.7% of the ambulatory visits made to FM specialists of all types, while those conditions accounted for only 10.6% of visits to FM clinics. The study demonstrated the relatively low proportion of chronic diseases that was managed in FM clinics in Taiwan, and our detailed results could contribute to evidence-based discussions on healthcare policymaking and residency training.

AIMS: The palliative care has spread rapidly worldwide in the recent two decades. The development of hospice services in rural areas usually lags behind that in urban areas. The aim of our study was to investigate whether the urban-rural disparity widens in a country with a hospital-based hospice system. METHODS: From the nationwide claims database within the National Health Insurance in Taiwan, admissions to hospices from 2000 to 2006 were identified. Hospices and patients in each year were analyzed according to geographic location and residence. RESULTS: A total of 26,292 cancer patients had been admitted to hospices. The proportion of rural patients to all patients increased with time from 17.8% in 2000 to 25.7% in 2006. Although the numbers of beds and the utilizations in both urban and rural hospices expanded rapidly, the increasing trend in rural areas was more marked than that in urban areas. However, still two-thirds (898/1,357) of rural patients were admitted to urban hospices in 2006. CONCLUSIONS: The gap of hospice utilizations between urban and rural areas in Taiwan did not widen with time. There was room for improvement in sufficient supply of rural hospices or efficient referral of rural patients.

Background: The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. Methods: This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. Results: A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). Conclusion: The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the differences in nurses' willingness to discuss palliative care with terminally ill patients and their family members. Methods: The participants were randomly recruited from registered staff nurses ≥20 years of age who were responsible for clinical inpatient care in a tertiary hospital in northern Taiwan. A semi-structured questionnaire was administered to evaluate nurses' experiences of discussing do-not-resuscitate (DNR) decisions and their willingness to discuss palliative care with terminal patients and their family members. The differences in nurses' experiences regarding DNR and willingness to discuss palliative care with terminally ill patients and their family members were compared using the Chi-square test. Logistic regressions were used to analyze factors associated with nurses' willingness to discuss palliative care with patients and their families. Results: More participants had experienced initiating discussions about DNR with patients' families than with patients (72.2% vs 61.9%, p < 0.001). Unadjusted logistic regression analysis showed that the experiences of actively initiating DNR discussions with patients were a significant factor associated with palliative care discussion with patients (odds ratio [OR] = 2.91, 95% confidence interval [CI]: 1.09-7.79). On the other hand, the experiences of actively initiating DNR discussions with patients and with patients' families were significant factors associated with palliative care discussion with patients' families (OR = 3.84, 95% CI: 1.22-12.06 and OR = 3.60, 95% CI: 1.19-10.90, respectively). After adjusting for covariates, no significant factors were found to be independently associated with nurses' willingness to discuss palliative care with patients and their family members. Conclusion: There are significant differences in nurses' willingness to discuss palliative care with patients and their family members. Further research is needed to evaluate factors associated with nurses' willingness to discuss palliative care with patients and their families to facilitate these discussions and protect patients' autonomy. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to investigate the effect of COVID-19 on the outpatient advance care planning (ACP) services provided by veterans hospitals in Taiwan. Methods: This study adopted a retrospective data analysis. We investigated ACP services provided by 15 veterans hospitals in Taiwan from 2019 to June 2020. We also conducted a statistical analysis on the ACP services provided by the Taipei Veterans General Hospital. Results: From 2019 to June 2020, 15 veterans hospitals in Taiwan provided ACP services to 2493 individuals. The outpatient ACP services declined significantly after January 2020, decreasing from a national average of 206.2 ± 29.2 declarants per month to 106.2 ± 30.8 declarants per month in the 6 months immediately following the COVID-19 pandemic outbreak (p < 0.001). From the official implementation of the ACP in January 2019 to the end of June 2020, a total of 1126 declarants accepted ACP services at the Taipei Veterans General Hospital. When the COVID-19 pandemic was prevalent, the declarants who received ACP services were younger (i.e., 60.1 ± 15.2 vs 65.5 ± 16.3 years; p < 0.001). After the variables had been adjusted, the changes in the characteristics of the declarants receiving ACP services when the COVID-19 pandemic was prevalent were as follows: a significant increase in the percentage of hospital staff receiving ACP services (odds ratio [OR]: 5.460, 95% confidence interval [CI]: 2.378-12.536); An increase in the percentage of declarants who paid for the ACP services received at their own expense (OR: 3.417, 95% CI: 1.591-7.339); and an increase in the percentage of declarants who received the consultations with three or more people (OR: 2.017, 95% CI: 1.278-3.182). Conclusion: COVID-19 severely changed outpatient ACP services provided by hospitals. The results obtained by this study offer valuable insight regarding the provision of outpatient ACP services. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19), a novel infectious coronavirus disease, has become a worldwide pandemic. Infection control precautions for hospital visitors are needed to avoid cluster outbreaks, so this study investigated the visiting policies of all the hospitals in Taiwan in the time of COVID-19. Methods: From March 15, 2020, to March 18, 2020, we searched the official websites of all 472 National Health Insurance--contracted hospitals to determine their visiting policies. For those hospitals that had posted new visiting policies and still allowed visits to ordinary wards, we recorded the relevant details shown on their websites, including the number of visitors allowed at one time, the number of visiting slots per day, the total visiting hours per day, and the rules provided to visitors before visiting. Results: During the study period, 276 (58.5%) hospitals had posted new visiting policies on their websites, with higher proportions of academic medical centers (92.0%, 23/25) and metropolitan hospitals (91.5%, 75/82) than local community hospitals (48.8%, 178/365) doing so. Visits to ordinary wards were forbidden in 83 hospitals among those. Among the 193 hospitals that had new visiting policies and still allowed visits to ordinary wards, 73.1% (n = 141) restricted visitors to two at a time and 54.9% (n = 106) restricted visits to two visiting slots per day. Furthermore, history taking regarding travel, occupation, contacts, and cluster information was mentioned by 82.4% (n = 159) of these 193 hospitals, body temperature monitoring by 78.2% (n = 151), hand hygiene by 63.2% (n = 122), and identity checks by 51.8% (n = 100). Conclusion: In the time of COVID-19 covered by this study, about three-fifths of the hospitals in Taiwan had posted their visiting policies for ordinary wards on their websites. Furthermore, the thoroughness with which such visiting policies have been enforced also requires investigation. [ABSTRACT FROM AUTHOR]